What consideration should be given to the resident from another culture when death is imminent? This account of Georgiou’s death illustrates the unfortunate and unhappy consequences of ignoring a resident’s primary cultural need. Reflection on practice shows that, in this instance, the cultural needs of the resident and his wife may have been more adequately met by careful listening, lateral thinking and continuous re-evaluation of the plan of care. As well as offering Georgiou some choice about where he wanted to die, the outcome may have turned a widow’s guilt, frustration and resentment into long-lasting satisfaction and fulfilment. While there will never be another Georgiou, what we learn from his story may broaden our vision by alerting us to consider cultural factors more carefully.
Georgiou’s name was on the waiting list intermittently for nine months, while his wife struggled to care for him at home with minimal assistance, putting off the inevitable. Then, the inevitable happened. He fell, broke his leg and was admitted to hospital. ‘This is it,’ Anna decided. ‘I won’t be able to take him home this time.
He’ll have to go to the nursing home.’
Revised forms were completed, the assessment team’s decision was clear. Taking into account Anna’s failing health and in the absence of extended family support, admission to a nursing home appeared to be the only course of action. The local doctor was relieved to have the situation resolved.
Georgiou however, perceived to be too confused to be asked for his opinion regarding moving to a nursing home, had firm ideas of his own. He didn’t like the
hospital food, he missed his wife who could only travel the long distance from home to hospital once a day and had to leave early to catch her bus to get home before dark. He became restless and agitated and Anna could see he was fretting. ‘Well,’ she reasoned with the social worker, ‘he won’t be able to wander off now, so he’ll be easier to manage at home. Will you please tell the nursing home I’ve changed my mind. I’m taking Georgiou home instead.’
Knowing Anna well, from our many phone calls and her frequent visits to the nursing home, we kept his name on the waiting list. The doctor, social worker and community nurses were quite sure the situation would soon break down and Anna would be forced to admit Georgiou for long-term care.
About six months later Anna visited to confirm her husband’s place on the waiting list ‘just in case’. It was clear she was at breaking point. Georgiou’s fracture had healed and he was as active as ever. Only the night before, he had mistaken the drying cabinet for the toilet and then managed to get himself wedged behind the bathroom door. Anna could cope with his incontinence while he was in bed, but his unpredictable wandering was causing increasing frustration and strain. Georgiou would allow Anna to wash and feed him but would have nothing to do with the visiting nurse. Attempts at respite care had failed miserably; Anna spent her time worrying while Georgiou occupied himself trying to get out of bed so he could go home. Also there was a new problem: Georgiou had been diagnosed with lung cancer. He was losing weight and seemed to be in pain. The doctor knew it would be difficult to proceed any further with tests and tried gently to persuade Anna that Georgiou needed specialised nursing care to keep him comfortable and pain free.
Anna understood all about comfort. She knew how Georgiou relaxed when she lay beside him at night, gently stroking his forehead or massaging his back. In spite of all the complexities of incontinence, she had somehow managed to nurse him in the bed they had shared for over 40 years. She also knew that he would be less likely to attempt to get out of bed at night while she was beside him. Yes, Anna knew all about that kind of comfort, but as for symptom control for cancer, of that she had no knowledge at all, so it was best to ignore those harsh realities. So she continued to do her best. As Georgiou became progressively weaker Anna became increasingly tired, her arthritis worsening because of the constant strain of lifting and turning him. Finally, when she allowed her blood pressure to be checked, the doctor had to be quite firm, ‘Who will look after him if you have a stroke?’
As often happens, coincidental factors came together at the right time. A bed became vacant in our nursing home and Anna’s decision had to be made quickly.
Georgiou, by now quiet and withdrawn, did not seem to object to the move and Anna set about labelling clothes, cooking special delicacies and visiting at every meal time. We were quick to make assumptions — Anna would now enjoy the rest she deserved. No longer having the worry of caring for her husband day and night, at last she would be able to look after herself. We would persuade her to visit only once per day, although she lived close by. ‘Anna, you must take care of yourself; we’ll take care of Georgiou.’
There was, however, another side to the story which, despite all our caring, was never fully appreciated. Steeped in her own cultural expectations, Anna felt she had deserted her husband; handed him over to strangers. Although she had no other family in Australia, her close-knit Greek community kept a watchful eye over events.
While she received some sympathy and understanding from her friends, she believed she was shunned by others, blamed for giving in too easily. Her guilt increased when she saw Georgiou’s condition deteriorate. Unfortunately, no-one ever took the time to explain that the tumour was growing rapidly, so Anna was left to draw her own conclusion — he was fretting. Georgiou became restless and agitated whenever she visited; withdrawn and morose when she left. When well-meaning staff could see Anna’s health declining they offered plenty of suggestions: ‘Why don’t you stay home and rest. We’ll look after him. We’ll ring if we think he needs you.’ Anna knew perfectly well that her husband wouldn’t eat the nursing home food and would probably not eat anything unless she was there to feed him. While it was nice of the nurses to offer, how would they know when he needed her? In spite of frequent reminders about the nursing home laundry, Anna continued to take all his soiled washing home, returning it spotless and perfectly pressed. As far as Anna was concerned there were no other options, this was her labour of love for her husband.
It was also a source of pride that her friends could see she was a dutiful wife.
However, it was not easy for the staff. They were puzzled when the normally cooperative Anna became critical and suspicious of all nursing care offered to her husband. She disliked the hard, hospital linen and longed to check her husband’s skin but the nurses seemed defensive about it. He certainly had no pressure marks when she cared for him at home, protecting his skin with the softest of linen which was carefully removed and meticulously washed immediately it was soiled. These disposable pads must certainly cause chafing and what was this medicine they were giving him? ‘It’s to help the pain,’ was the repeated explanation. When the
injections started, Anna became absolutely convinced her husband was being drugged in order to keep him quiet. When she had time to discuss the situation with her friends they agreed that it must be the morphine and ‘once they start with that, it’s the end!’
Georgiou’s condition changed. As the result of pain relief, he became clearer in his thoughts and his faltering English easier to understand. Whilst accepting all care offered, he continually appealed to each nurse to ‘please let me go home’. Although he had lost the physical energy required to climb over the bedrails that Anna had insisted upon, no-one had thought to suggest to Anna that she could let the bedrails down when she was sitting with him. Now there was an intolerable steel barrier between Anna and her husband. At each visit, hands clasped through the rails, Georgiou pleaded with her to take him home.
Again the problems escalated. Staff became impatient with Georgiou’s repeated requests to go home and defensive of Anna’s intense preoccupation with every aspect of his care. Why was he still in the same shirt that he wore yesterday, with its unsightly stain from spilled food? Why haven’t his teeth been cleaned? Where is his own small blanket, the one that gave him so much comfort when tucked up round his shoulders? Checking whether he was in a wet bed became an obsession for Anna. Furthermore, she had become quite friendly with two other women from the ‘old country’ who regularly visited their husbands in the nursing home.
They could frequently be seen in a cluster, talking rapidly, leaving staff with the impression that more criticism was being levelled at them. From all angles, this was becoming a very difficult situation. Everyone was frustrated and no-one had an answer.
When Georgiou’s death was imminent Anna’s visits increased in length and frequency. Having stayed all through the night on several occasions she was counselled on this night to go home and get some sleep. Although expecting the inevitable, when Georgiou died at 11 p.m., Anna was totally unprepared for the phone call and become hysterical. Her doctor responded by prescribing
a sedative.